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Suggested Guidelines for the Assessment of Children and Adolescents with Selective Mutism
Marcus Crenshaw, Ph.D. |
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The assessment of children with Selective Mutism (SM) presents a number of challenges that are not present when performing “typical” psychological evaluations. This paper describes a number of guidelines that may be useful to address some of the unique problems that arise in such evaluations. It should be seen as suggestive, rather than prescriptive, and a flexible and responsive approach in these evaluations is recommended.
While there are unique facets to be considered in the evaluation of children with SM, some of its facets are common to all psychological evaluations. As with any comprehensive psychological evaluation, it is important to obtain detailed developmental, family, and medical histories as they pertain to the child and his family. The goal here is, of course, to determine whether any factors in these histories shed light on the development of SM or any other areas of functioning in the child undergoing evaluation.
In the case of a child or adolescent presenting with SM, a unique type of “history” should also be explored. This unique history pertains to incidents and conversations that have occurred as a direct result of the child’s SM (and associated symptoms). These incidents and conversations have the potential to influence the behavior, attitudes, and feelings of the child, as well as those of others who have contact with him/her. Through natural learning processes, they also have the potential to influence the child’s prognosis, and knowledge of them may provide clues to the most effective therapeutic regimen for that particular child.
For an example of these ideas, contrast the situation of one child whose parents have attributed his SM to willful disobedience with that in which the parents believed from the beginning that the child failed to respond due to issues related to fear and anxiety. Obviously, the attributions held by the parents in these two cases would create different interactions as they relate to the SM with the two children.
In addition to the attributions that others have regarding a child’s mutism, and the attendant interactions that may take place as a result, specific “incidents” may occur in a child’s life that would ideally be known by the evaluator. For example, in one case, a parent reported the following incidents: The kindergarten teacher of this child with SM reportedly threatened punishment if she would not talk. On one occasion, she followed through on the punishment, which consisted of a Time-Out period of several minutes. This same child reportedly spoke to a bus driver who got lost one afternoon, and this child was apparently the only child on the bus who knew the way to her house. On one occasion, this girl was hit in the shoulder by a boy because she would not talk. Knowledge of events such as these, as well as positive events related to the child’s SM (e.g., the child attending a special program for children with SM) can enhance the evaluator’s perspective regarding the manner in which the SM has uniquely affected the child’s life.
A related consideration is the child’s knowledge of selective mutism. There is potential value in the answers to basic questions such as: What has your child been told about selective mutism? Does she know that other children have the disorder? Do you purposely avoid discussing your child’s speech inhibition with her? What terms or phrases are used to indicate that your child has difficulty getting the words out? (e.g., “she is shy”, “she doesn’t talk”, “it takes a while for her to feel comfortable around new people”, etc.)
Two Component Approach to Assessment of Children with Selective Mutism. In order to complete a comprehensive evaluation of a child or adolescent with selective mutism, it is advantageous to conceptualize the task in terms of two major components. The first component, which addresses the ways in which the child’s selective mutism is manifest, and what emotional correlates are present, must be understood if one is to plan and conduct an appropriate assessment of the child. The broad question to be addressed by this component is: How is this child affected by the selective mutism? By extension, it is of interest to know how the child’s family, friends, teachers, and others with whom the child has contact are “affected by” the child’s selective mutism. More to the point, what do others believe the mutism represents, and how have their beliefs affected their interaction (and relationships) with the child with selective mutism?
Component 1A: The Child’s Communication Capabilities and Behavioral Inhibition. The first considerations in this area are the child’s current communication capabilities, and the manner and extent to which his communicative behavior is inhibited (vocally, verbally, and nonverbally). Lack of understanding of the child’s communication capabilities, or limitations due to behavioral inhibition, could seriously hamper the evaluation and substantially limit its value. Therefore, an evaluator is well-served when she knows the child’s communication capabilities, as well as settings and circumstances that influence (or are likely to influence) the child’s communicative behavior.
The inhibition of behavior, in my view, is the major objective feature of SM, and it is important to explore all facets of the child’s behavioral inhibition. This is important in order to devise an appropriate assessment strategy, as well as providing a baseline of functioning that may be used to evaluate progress or other changes over time.
While some researchers recognize that children with SM are behaviorally inhibited in ways that extend over and beyond their speech inhibition, Dr. Shipon-Blum (2003) has emphasized this fact in her writings, and it has become one of the major principles upon which her therapy is based. To illustrate these ideas, it is helpful to distinguish between vocal, verbal, and nonverbal behavior, and to acknowledge that inhibition may occur in any (or all) of these expressive modalities. Skillful and adaptive communication involves unfettered expression in all of these modalities, and communication is limited when expression in any modality is inhibited.
Another way to view communication is through the three communication tasks that comprise fully functional social communication. These fundamental tasks include:
1. engagement with others, 2. responding to the communications initiated by others, and 3. initiation of communication in the service of one’s own needs or desires
To illustrate the value of knowing the SM child’s communication capabilities, as well as understanding the nature and extent of her behavioral inhibitions, consider the serious mistake an hypothetical evaluator would make if he attempted to evaluate a child without knowing that the child would have felt comfortable whispering to her mother during the evaluation. Another hypothetical evaluator might miss the fact that the child she is evaluating is comfortable producing written responses. Throughout the evaluations conducted by these hypothetical evaluators, these important potential sources of information would be lost simply because they were not aware of the relevant facts.
Component 1B: The Issue of Anxiety While estimates vary, most researchers have found a high degree of association between children with selective mutism and co-existing anxiety “issues” (whether they constitute full-blown disorders or are simply seen as symptoms of other disorders.) Given this fact, it is important to determine whether a child with SM also manifests symptoms of other anxiety disorders. A variety of psychometrically sound measures have been developed which are helpful in the assessment of childhood anxiety disorders. Most of the measures that have been developed are in the form of semistructured interviews or rating scales which are to be completed by the parent or teacher of the child. A number of self-report measures for children and adolescents are also available. A brief overview of some of these measures is provided below:
1. The Anxiety Disorders Interview Schedule for DSM-IV—Child and Parent Versions (ADIS-C/P; Silverman & Albano, 1996). A structured interview designed to assess for current episodes of anxiety disorders, and to permit differential diagnosis among the anxiety disorders according to DSM-IV criteria.
2. Child Symptom Inventory-4—(Gadow & Sprafkin, 1994). A behavior rating scale completed by parents or teachers. Responses yield dimensional indices of adjustment, as well as separate scores in General Anxiety Disorder, Social Phobia, and Separation Anxiety Disorder.
3. Screen for Child Anxiety Related Emotional Disorders—Parent Version (SCARED; Birmaher et al., 1997). Five factor domains are derived from responses: Panic/Somatic, Separation Anxiety, General Anxiety, Social Phobia, and School Phobia.
4. Multidimensional Anxiety Scale for Children (MASC; March, 1998). Self-report instrument that yields a Total Anxiety Disorder Index and four main factor scores (with subfactor domains noted in parentheses as applicable): Social Anxiety (performance anxiety, humiliation), Physical Symptoms (tension-restlessness, somatic-automatic arousal), Harm Avoidance (perfectionism, anxious coping), and Separation/Panic.
5. Screen for Child Anxiety Related Emotional Disorders-Revised (SCARED-R; Birmaher et al., 1997). A self-report instrument for children and adolescents that yields scores in the areas of generalized anxiety disorder, social phobia, separation anxiety disorder, panic disorder, obsessive-compulsive disorder, traumatic stress disorder, and the types of specific phobias. A parent version is also available.
Component 2: Everything Else. The second component involves assessment of all other aspects of the child that are of interest. Given the multifaceted nature of SM, and especially since different settings have such a strong effect on its manifestations, it is most appropriate to perform an evaluation of children with SM that fulfills the requirements of the “multisetting, multisource, multi-instrument” assessment model (Martin, Hooper, & Snow, 1986), as much as possible. This provides the best assurance that the results of evaluation are valid and optimally useful in the development of an effective therapeutic plan.
General considerations in working directly with children with selective mutism. Although it is always important to establish rapport with children prior to evaluating them, this seems particularly important when evaluating a child with selective mutism. Children with selective mutism tend to be highly sensitive to the presence of other people, as well as being sensitive to the settings and circumstances in which they find themselves. The result of this, from the child’s viewpoint, is the tendency for her level of social comfort to vary, depending on these factors. Consequently, the evaluator should take extra care and exercise certain precautions to avoid creating a counterproductive impression during the evaluation. Below are some suggestions that may help prevent this from occurring.
1. Warm-up Time. Related to the issue of rapport is the very consistent finding that children with selective mutism require more “warm-up” time than is typical (Shipon-Blum, 2004). This is to say that they need more time to feel comfortable and natural in a new setting or situation. One implication of this fact is that formal evaluation procedures might need to be postponed until the child feels more comfortable with the examiner, or in the evaluation situation. Indeed, some SM children may require multiple sessions with the evaluator before they perform at a level on which they are capable.
2. Choice. One of Dr. Elisa Shipon-Blum’s profound discoveries in working with SM children relates to the issue of “choice”. In short, she has found that the SM children with whom she works tend to respond much more readily and comprehensively when she creates a climate replete with choices for the child to exercise (E. Shipon-Blum, personal communication, July 26, 2005). This discovery obviously has implications for the treatment of children with SM, in that it appears to expedite the treatment process. It also has important implications for the evaluator of these children, since it suggests that the provision of some choices within the context of the evaluation might inspire more natural responses in the child. The result, of course, would be the display of more direct behavior upon which to integrate into the overall evaluation results.
3. Eye Contact. Another discovery that may be attributable to Dr. Shipon-Blum relates to “eye contact”. Clinical experience has led her to conclude that many of these children are uncomfortable when unfamiliar people give them direct eye contact (Shipon-Blum, 2003). One implication of this is the suggestion that the evaluator of children with SM should be particularly aware of his/her own use of eye contact. This is not to say that no eye contact should be given. Rather, it is to suggest that it is important for the evaluator to be cognizant of this issue and respond accordingly. Insensitivity to this fact may have the effect of limiting the rapport that is established between the evaluator and child.
Assessment with minimally responsive children. When a child with SM’s behavior is extremely inhibited, it presents the greatest challenge to the evaluator. This is largely due to the child’s minimal display of interpretable behavior. Nevertheless, there remains much useful information that can be learned about a child’s characteristics, behavior, and abilities. The additional information is provided by the child’s parents and teacher, and it can provide a fairly comprehensive understanding of the child’s interests, behavioral and social status, and individual needs.
Parents as Informants. The parents of a child with severe inhibition can provide a great amount of information relating to their child’s experiences, interests, sensitivities, probable levels of ability and academic achievement, coping skills, moods, and other relevant characteristics and qualities. This information should be sought through in-depth interviews and supplemented by administration of a number of rating scales or other measures that have favorable psychometric characteristics. Some instruments that address broad areas of functioning, such as the BASC-2 (Reynolds & Kamphaus, 2004) and Child Behavior Checklist (Achenbach, 1991) are very commonly used, and they can provide clues to the existence of additional symptomatology and comorbid conditions.
Teachers as Informants. Assuming the child has been in school for at least several years, it is often helpful to determine how the child’s various teachers view(ed) the child, and what they have reported about the child. Areas of agreement in teacher reports, as well as areas of disagreement, are potentially helpful in understanding the child, and this information can be obtained through interview and a review of the child’s school records.
In addition to interviewing the child’s teachers and reviewing the child’s school records, much useful information can be gained through administration of the School Evaluation Form (published by the SMart Center Publications and available at no cost at http://selectivemutismcenter.org/htm/sef.htm). This instrument assesses the child’s levels of social comfort in a variety of school settings, academic levels, efficiency in starting/completing tasks, teacher’s ability to evaluate the child’s skills. Also tapped by this instrument are the child’s communicative behaviors with peers in large and small groups, teachers and extended school personnel, as well as that with parents present. Finally, information on school services is provided by the School Evaluation Form.
Functional Behavioral Assessment. The potential value of a well-planned and well-executed functional behavioral assessment (FBA) is extremely great because it may hold the promise of uncovering factors that play important roles in the maintenance of the SM symptomatology. The elucidation of environmental factors that influence behavior is, of course, one of the main objectives of an FBA. Fortunately, a number of advances in FBAs have occurred in recent years, making the practice well worth consideration in the interest of understanding the SM child’s inhibitions.
Although the typical approach implied by the term FBA is of direct behavioral observation, Bergan (1977; see also Sheridan, Kratochwill, and Bergin 1996) developed a number of structured interview protocols that provide essential information for an FBA. The information that can be obtained through these interviews goes well beyond a description of behavior, antecedents, and reinforcers. It can have practical value, as well, since the informant may have knowledge that suggests particularly fruitful times for observation, a variety of considerations that should be known prior to the observation, etc. The information obtained in the interview can, of course, be supplemented by that obtained through behavioral observation and through other sources, and the result can be a rich and highly valid portrayal of the target child’s behavior and environmental contingencies, resources that are available to address the problem, and a variety of other relevant facts and circumstances.
Specific rating scales have been developed that are also pertinent to the development of an FBA. Among the measures that may be useful are broad-band instruments such as the Devereux Behavior Rating Scale (Naglieri, LeBuffe, & Pfeiffer, 1993) and narrow-band instruments that are designed to measure specific behaviors (e.g., the Social Skills Rating System; Gresham & Elliott, 1990).
Direct observational strategies have been used in a variety of settings, and their value in assessing relationships between settings, antecedents, specific behaviors, and consequences has been well established. Since it is reasonable to assume that there is a certain immediacy in the factors that influence the SM child’s behavior, a direct observational strategy would seem well suited to provide important information.
As with all other data-gathering approaches, however, observational strategies suffer from weaknesses, as well. The problem of reactivity has been repeatedly noted in the literature and, given the apparent sensitivity of many children with SM, it would seem particularly important in these cases to employ measures to minimize this effect. The use of multiple observers over time, ensuring that the target child is not aware of the plan to observe him/her, and taking care to observe unobtrusively, are some possible ways to reduce the reactivity of the observation.
Special Method: Videotaping of SM child at home and in other situations: The viewing of videotapes which feature the child with SM (as well as other family members) can be helpful in assessing a variety of domains. Given the popularity of consumer-level video cameras, many families make videos of their members to mark special occasions, as well as doing it just for the fun of it. Some of these “unstaged” videos can be useful in an appraisal of some aspects of the child’s speech and language skills, as well as providing valuable clues regarding the child’s apparent levels of social comfort or discomfort in typical social events (such as birthday parties, family gatherings, etc.).
In addition to providing clues regarding the child’s levels of social comfort, unstaged videos can provide information regarding her social skills, general demeanor, and behavioral tendencies. The strong influence of environmental determinants should always be borne in mind when interpreting videotape data, however, and one implication of this fact suggests that the “data” obtained through these be seen as suggestive, rather than definitive indicators of stable traits or characteristics.
In addition to unstaged videos, and if the parents and child are willing, there are a number of “staged” approaches that may also be valuable in the assessment. In one approach, a parent can ask specific questions that have been carefully selected by the Speech and Language Pathologist to help ascertain comprehension or expressive language skills. Similarly, specific content areas can be assessed through this medium. For example, if the child feels comfortable reading specific and specially chosen materials, this can lead to estimates of skill levels in the areas of reading rate, reading fluency, and word attack. (If the child is extremely inhibited in the school environment, this approach might also be considered for the examination of other areas, such as math skill, math reasoning, and written expression). Any “results” obtained in this manner, however, would need to be interpreted with some caution. That is to say, the resulting scores should be considered rough estimates, as opposed to more precise indicators of achievement.
Assessment of a child who reliably provides pointing or other nonverbal responses. The SM child who reliably provides pointing or other nonverbal responses increases the number of direct assessment options dramatically. There are a wide variety of measures that only require pointing responses, writing, or simple nonverbal responses, and they can provide a surprising array of information regarding ability, academic achievement, personality structure, etc.
Intellectual functioning. Most of the nonverbal intelligence measures available are unidimensional in nature. In contrast, only two of the widely used measures are multi-dimensional (i.e., the UNIT and the Leiter-R). Both of the multi-dimensional measures have strong psychometric characteristics, but the Leiter-R is seen as a more useful measure. In addition, the Leiter-R provides rating scales that can be completed by the Examiner, Parent, Teacher, and Child him/herself. The domains that are included in the ratings seem particularly helpful in the assessment of a child or adolescent with SM. They are: attention, activity level, organization/impulse control, sociability, sensory reactivity, emotions, anxiety, and mood.
While multidimensional measures of intellectual functioning are seen as being of greater value than unidimensional measures, time constraints and other factors may make the use of one of these measures more reasonable. Among these measures are the Comprehensive Test of Nonverbal Intelligence (CTONI), the Test of Nonverbal Intelligence-Third Version (TONI3), the Raven Progressive Matrices, and the Naglieri Nonverbal Ability Tests (NNAT and MAT-EF).
Academic achievement. As with any child, much information can be gained through inspection and appraisal of an SM child’s school work. In-depth interviewing of the child’s teacher (and, ideally, former teachers) can also help in an appraisal of the degree to which the child’s work meets grade-level expectations. It should be borne in mind, however, that behavioral inhibition can have direct and indirect effects on a child’s school performance. Therefore, these types of assessments should be viewed as providing information that may have the potential to assist in educational planning, as opposed to providing “absolute” estimates of academic achievement.
A variety of individually administered achievement tests that only require nonverbal responses are available. The selection of tests (and particular subtests, in some instances) should be based, of course, on the responses required for the administration, and the degree to which the child feels comfortable responding in the required manner.
Personality characteristics. It is common practice to employ nonverbal methods in the appraisal of personality and psychopathology. Unfortunately, much of this has been done without empirical validation of the methods in question. Some advances have been made in this area, but it has been noted that some practitioners have shown disregard for the limitations of some of these assessment techniques.
There are several types of nonverbal approaches to personality assessment. Among these types are:
1. Drawing techniques, which include drawings, depictions, or reproductions of persons, objects, and figures (e.g., Bender-Gestalt Test, Draw a Person, House-Tree-Person, Kinetic Family Drawing)
2. Object placement and play techniques, which involve the arrangement of materials and manipulatives in meaningful and interpretable ways (e.g., Erica Method, Family System Test, Mosaic Test, SandPlay, and World Technique)
3. Self-rating and self-report techniques, which involve the rating of a pictorial stimulus as it personally relates to oneself (e.g., Five-Factor Nonverbal Questionnaire, Nonverbal Personality Questionnaire, Visual Analog Mood Scales)
The listing below is limited to some of the techniques that have a degree of empirical support. It should be noted that some of the tests and procedures that lack empirical support can be useful as “warm-up” activities, since they are nonthreatening and many children enjoy the activities. Also, even without firm empirical support, the results of some of these activities can be useful in the generation of hypotheses regarding the child being evaluated. Follow-up activities or interviews can then be used to explore the identified issues in more depth.
1. Drawing techniques:
a. Draw a Person: Screening Procedure for Emotional Disturbance (DAP: SPED; Naglieri, McNeish, & Bardos, 1991)
b. The Levick Emotional and Cognitive Art Therapy Assessment (LECATA; Levick, 2000)
c. The Diagnostic Drawing Series (DDS; Cohen, Hammer, & Singer, 1988)
2. Object Placement and Play Techniques:
a. The Family System Test (FAST; Gehring, 1998)
b. The Erica Method (Sjolund, 1981)
3. Self-Rating and Self-Report Techniques:
a. Behavior Assessment System for Children, Second Edition: Self Report (Reynolds & Kamphaus, 2004)
b. Nonverbal Personality Questionnaire (NPQ; Paunonen & Jackson, 1998; Paunonen, Jackson, & Keinonen, 1990)
c. Five-Factor Nonverbal Personality Questionnaire (FF-NPQ; Paunonen, Ashton, & Jackson, 2001)
d. Visual Analog Mood Scales (VAMS, Stern, 1997)
Nonverbal Neuropsychological Assessment: A large number of tests and specific subtests that are essentially nonverbal in nature have been developed to assess the various domans of neuropsychological assessment. Among the areas assessed by these measures are:
1. Attention (including selective attention, sustained attention, divided attention) 2. Response Inhibition 3. Planning and Organization 4. Cognitive Flexibility and Mental Set Shifting 5. Spatial Cognition 6. Visuospatial Perception 7. Perceptual-Motor Integration 8. Memory and New Learning, Long-term Memory, Working Memory
Excellent resources are available that describe in detail measures in these and other areas. Among these are the Handbook of Nonverbal Assessment (McCallum, 2003) and the Handbook of Normative Data for Neuropsychological Assessment (Mitrushina, Boone, & D’Elia, 1999). These books place the role of nonverbal neuropsychological assessment in its proper context, as well as providing administration and interpretive information for a wide variety of measures of executive functioning.
Family Assessment. It is important in all cases to ascertain detailed information regarding the family of the child with SM. This follows from the fact that parents are the primary educators of the child, and it is well established that their characteristics, attitudes, behavior, interpersonal functioning, and even the nature of their emotional experiences can have profound effects on the children they raise. This information can be obtained through interviews with the parents, formal measures of family functioning, or a combination of these approaches. Of course, observation of the family’s interaction can also shed some light on these issues.
Many psychometrically sound measures of family functioning have been developed, and two resources in this area that may be of value are Family Assessment: A Guide to Methods and Measures (Grotevant & Carlson, 1989) and Family Assessment: Integrating Multiple Clinical Perspectives (Cierpka, Thomas, & Sprenkle, 2005).
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Copyright 2006 Dr. Marcus Crenshaw |